Stratifying Risk When Discharging Patients to Post-Acute Care

By Luis Castillo, President and CEO of Ensocare

Luis Castillo, President and CEO of Ensocare

When patients move from a hospital to the post-acute setting, it can be risky. There is strong evidence suggesting that poor communication and information-sharing during this time can lead to negative consequences, including care plan confusion, redundant or unnecessary testing, intermittent patient monitoring, medication errors, diagnosis and treatment delays and a lack of follow through on referrals. Any of these care lapses can create a situation in which patient safety is compromised, increasing the chances of poor patient health outcomes and hospital re-admission, while driving up care costs. However, there is also research that indicates hospitals and health systems that stratify patient risk, communicate throughout discharge and enable care coordination can lessen the hazards associated with this tricky period.

Stratify Risk

The process of determining a patient’s propensity for post-discharge problems should begin when the patient arrives at the hospital. Oftentimes, physicians and nurses have a sense right from the beginning of care whether the patient will require post-acute treatment and whether they will be at risk for readmission. For example, an elderly patient with several co-morbidities and limited family support who needs to go to a skilled nursing facility to recover from a total knee replacement is going to be at much greater risk than a younger patient having the surgery who is otherwise in good health and has a family member helping navigate the next steps of care.

"With some solutions, staff can even show patients and families brief videos of each site, so they can better visualize the options"

Hospitals should leverage clinician insights, creating a process for clinicians to alert care coordinators as soon as they determine that the individual is going to require additional attention. This allows care coordinators to funnel the patient towards a more customized discharge approach.

Offer Well-vetted Options

As soon as the discharge team learns of a high-risk patient who needs post-acute care, they should take action to identify options for the next setting. The more information the hospital provides to the patient and family about different possibilities, the more likely they are to make an informed choice. By starting early, staff gives the patient and their family more time to make an informed decision without feeling rushed.

To facilitate the process, hospitals should consider using care management software that enables more targeted placement. These types of solutions let care coordinators identify potential matches that not only meet patients’ clinical requirements, but also their social and emotional needs, geographic preferences and insurance constraints. Staff members enter a patient’s requirements into the program, and the technology uses data analytics to generate a list of possibilities that meets the patient’s needs. The tool then automatically sends a request to these post-acute providers, asking if they are available and willing to accept the patient. Upon receiving the detailed request, the post-acute providers decide whether to assume the patient’s care, sending back a timely response. In some cases, providers can receive information and send their responses using a secure mobile app, so they are able to communicate from anywhere in the facility, not just at their desk. This ensures the hospital receives a prompt response—sometimes in less than 30 minutes.

Armed with a pre-qualified list, the care coordinator can meet with the patient and family and provide information about the various facilities. In addition to demonstrating that a location meets the patient’s needs, the coordinator can use the technology to share patient satisfaction scores, readmission rates and quality information. With some solutions, staff can even show patients and families brief videos of each site, so they can better visualize the options. All this information helps the patient and family make an educated choice about next steps.

Proactively Communicate

Once the patient selects a facility, the hospital should reach out and share information with the organization. Again, technology can streamline the process. Through care coordination software, staffs are able to send relevant portions of the medical record to the post-acute provider, allowing the receiving organization to order appropriate medications and therapies ahead of time and be prepared to hit the ground running when the patient arrives onsite. Traditionally, there has not been a lot of preemptive communication between hospitals and post-acute providers. In fact, patients sometimes arrive at a post-acute facility with their entire medical record on their laps. Often, the receiving organization doesn’t have the time or resources to page through the medical record looking for relevant information. If staff brush off this task, however, it increases the chances of delayed, missed or omitted therapies. Conversely, by sending clear, concise and relevant information via the care coordination solution, hospitals can ensure the post-acute provider has all the necessary information to continue treatment without interruption.

Keep Information Flowing

Even after a patient transfers to the post-acute organization, it is beneficial to keep tabs on the individual and how he or she is progressing. That way the hospital can intervene if things start to take a turn for the worse. To foster cross-continuum communication, organizations may want to use a mobile care management platform, which acts as a virtual command center for care coordination. Team members, including the hospital discharge staff, post-acute provider, and patient and family can use the app to share information and respond to concerning trends.

The Difference between Recovery and Readmission

By risk-stratifying discharge and leveraging care coordination technology, organizations can effectively match vulnerable patients with post-acute providers, reducing the possibility of readmission and boosting patient satisfaction. So much of a patient’s success after hospital discharge is related to things other than just clinical care—appropriate support, good emotional health, convenient care options and the ability to access resources. By helping patients select a provider that fully meets all their needs—and engaging in proactive and collaborative communication with that provider—hospitals can improve the likelihood their patients will proceed toward recovery and avoid hospital readmission

Weekly Brief

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